What if unhealthy Americans could reap financial rewards for losing weight or quitting their cigarette habits? Would they do it? Congress wants to know, and may be on track to require insurance companies to offer premium discounts to people who take care of themselves.
This latest wrinkle in health reform comes from Rep. Kathy Dahlkemper, D-Pa., a dietician who looked at the health insurance-related bills coming out of various House committees and found something missing – namely personal responsibility. "What about the individual and our own responsibility?" she asked in a phone interview with Politics Daily. "How can we encourage people to make better lifestyle choices so that we bring down the cost of health care for the long term?"
The operative word is "encourage." This is all about carrots and not about sticks – kind of like an automobile insurance policy that gives you a break for safe driving but doesn't raise your rates if you cause accidents.
would require insurance companies to offer "premium discounts for healthy behavior and improvements toward healthy behavior," in an amount to be set by the secretary of Health and Human Services. The discounts would apply to six indicators of health: smoking, blood pressure, weight or body mass index, blood sugar levels (in diabetics), LDL (bad) cholesterol and HDL (good) cholesterol
Leonard Fleck, a professor of philosophy and medical ethics at Michigan State University, calls those categories easy to measure -- and hard to lie about. You can't fake a blood pressure reading, he said, or the nicotine levels in a blood test. Furthermore, most of the conditions are directly linked to serious, expensive consequences including cancer, heart disease and stroke.
It sounds like a win-win. Nudging people toward better health is good for them and, to the extent that it reduces chronic disease and costs to the health system, good for society and the economy. But this is personal health and government regulation we're talking about. So of course it's not quite that simple, ethically or politically.
Is it fair?
In some ways this is a straightforward path to bringing down health care spending, one that some states and private insurance companies already have taken. Some people could improve their health and qualify for discounts simply by remembering to take their medications. They could lose weight by eating more vegetables and less fast food. They could get more exercise.
On the other hand, some people have genetic predispositions toward obesity or high cholesterol. If you are disabled, maybe you can't exercise. If you live in an inner city, you may not have easy access to cheap, healthy food. "The question is always, is it fair to penalize poor people who already have so many strikes against them?" says Meredith Minkler, a professor of health and social behavior at the University of California-Berkeley. In her view it is fair with cigarettes, because that's a single product strongly linked to premature death.
"In the case of obesity, it is much more difficult terrain ethically," she said. That's because the causes and effects of obesity are less clear, and poor people "are under the most stress and have the most incentive to eat unhealthy foods, which are less expensive."
Beyond those questions, isn't a reward for some people tantamount to a penalty for others? Alabama has a new program that underscores the dilemma. Starting Jan. 1, 2010, the state will offer $25-per-month "wellness premium discounts" to state employees who have healthy readings in categories similar to those in Dahlkemper's bill. In following years, the discount will also be available to people who make efforts to improve. The state insists it's a positive incentive, but the National Conference of State Legislatures says Alabama – unlike other states – is "eschewing the carrot" and getting tough
It's all in the framing. You could say insurance will cost $50 a month for state employees, but they can whittle that down to $0 if they don't smoke (existing $25 discount) and they qualify for the new "wellness" discount ($25). Or, you could say insurance is free
unless they smoke and don't qualify for the wellness discount, in which case they have to pay up.
Who should pay?
Some people say it's only right that those with unhealthy lifestyles pay a price for them. They are annoyed that their premiums, medical fees and Medicare taxes are subsidizing the illnesses of those who make bad health choices. One outspoken critic is "personal success strategist" James Arthur Ray.
"I'm not too excited to pay for a lung cancer case obtained by smoking two packs of Marlboros per day. What part of 'smoking has been proven to cause lung cancer' is unclear?" Ray wrote last month at The Huffington Post
. "Likewise, I'm not excited to pay for triple bypass for a person who's spent a lifetime eating burritos, Krispy Kreme and Snickers, whose idea of a workout is clicking the remote on their television."
Few people are. But how many unhealthy Americans could afford to do what Ray says he does: spend "a small fortune (outside of my insurance plan) on proactive health-sustaining solutions such as massage, acupuncture, nutritional supplementation, gym membership, organic foods and much more"? How many of the Snickers-eaters live near farmer's markets or organic groceries? How many of the smokers succumbed to peer pressure at age 12 and never had the money or insurance coverage for a smoking cessation program?
And lest we think this is entirely a class issue, "good" choices made by middle-class, affluent professionals don't necessarily cost society less. Type A personalities make enormous contributions, Fleck says, but they have a lot of self-induced stress in their lives. They are susceptible to early heart disease and other problems associated with high stress levels, and that costs both them and us.
Then there is the upper-class craze for running. Exercise is good, right? But if you continue to run past your mid-30s, and do it on hard surfaces, Fleck says, "you're really banging up your knees and you're going to need a knee replacement and that's going to cost me, a non-runner. Do I have the right to be angry?" Those people should switch to swimming, he adds.
Can it pass?
Dahlkemper says her bill's focus on positive incentives, as opposed to penalties, makes it politically "palatable" and more likely to become part of health reform. She has a powerful patron in House Speaker Nancy Pelosi, who jumped on her "wellness" idea when the freshman congresswoman first mentioned it in July and urged her to press forward. Pelosi told reporters Thursday that "there's a big interest springing" up in Dahlkemper's bill and called it "another issue in our galaxy of issues to play into this legislation." There's also interest in the Senate; Dahlkemper and her chief of staff say the Finance Committee bill due for release this week has similar provisions.
Since the proposal is so new, there's no clear sense of whether political hurdles might arise. America's Health Insurance Plans, the industry trade group, did not respond to a request last week for its position on the Dahlkemper bill. It seems minor, however, given that some plans already charge higher rates for smokers and that Congress is contemplating far more dramatic insurance regulations – including a ban on refusing coverage to people with pre-existing medical conditions.
Certainly, Dahlkemper's initiative could be branded "big government" interventionism, yet another example of nanny-state meddling. But it's worth noting that Alabama, which has gone farthest in terms of putting on the pressure, isn't exactly socialist territory. It is one of the most conservative states. It's also one of the fattest, with an obesity rate that is second worst in the nation
In the end, there is an inevitable logic to the Alabama approach and to Dahlkemper's bill. Whatever you call it, incentive or penalty or tough love, it amounts to the same thing: Take care of yourself or pay more. Ideally we will do things that make it easier for poor people to live healthier lives (incentives to get supermarkets into their neighborhoods?). Ultimately maybe we will bring about the kind of societal shift that has made it unacceptable to drive drunk or skip seatbelts. So take a walk and come home to a tasty veggie snack. One of these days it could save you some money.